Why the No-Pay Policy for In-Hospital Infections Failed

I told you so.

Three months ago, I blogged about the Medicare (CMS) “never events” list, diagnoses that Medicare will no longer reimburse hospitals for. In Medicare’s eyes, these diagnoses are totally preventable, should never happen and will not be reimbursed. I pointed out that several were in fact not 100% preventable despite any institution’s best efforts, and the rates of many of these occurrences would not fall to zero.

Now the esteemed New England Journal of Medicine has published a paper which confirms what I wrote back in July. Its 13 authors compared rates of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), two of the diagnoses on the “never events” list, with ventilator-associated pneumonia, a disease not on the list, as a control.

After reviewing data from 398 hospitals from before and after the establishment of the new Medicare rules, they found that quarterly rates of all three infections did not change and concluded that the “never events” policy was ineffective. The senior author of the study then tweeted “Our paper in NEJM - CMS non-payment policy didn't change infection rates. Do we need much stronger penalties?”

My answer to that question is “No.”

Penalizing hospitals did not work because we may have reached the lowest possible rates of infection already. Some infections will occur no matter what steps are taken. We are dealing with human patients and human care-givers. Perfection is not likely to happen.

Many people erroneously believe that all CLABSIs can be prevented with the implementation of strict sterile precautions when catheters are inserted. That has lowered infection rates but not to zero. Why not? In addition to the technique of insertion, CLABSIs can result from other factors. Solutions may become tainted. The integrity of the IV line itself may be violated during the administration of medications through the line. The dressing covering the line may loosen and allow bacteria to enter the puncture site. Patients may be immunosuppressed and unable to overcome even the slightest hint of contamination. Or maybe it’s just bad luck.

CAUTIs are also not totally preventable. Despite a major push to remove urinary catheters as soon as possible, some patients need them for days to weeks for many reasons. For example, there are patients who simply cannot urinate on their own due to old age, dementia, coma, paralysis, etc. Critically ill patients with marginal urine outputs need urinary catheters for monitoring. Patients who are incontinent of stool may contaminate their catheters despite the best nursing care.

No, much stronger penalties will not work.

How about if we simply decide what is an acceptable rate for these infections and aim for that?

The Apocalypse Is Near: Part III

The way I see it, we are getting closer to the end of civilization.

The Washington Post reports that SAT reading scores have dropped to their lowest level in 40 years. For 57% [that’s more than half] of those taking the test, the results suggest that success in college is unlikely.

A woman in Alaska fell off a 60-foot cliff while texting. She survived.

In a related story, a 14-year-old Connecticut boy removed the brakes from his bicycle. He then got on it, ran a stop sign and crashed into a car. Surprisingly, he was not wearing a helmet.

A woman in Dallas suffers from “chemical and electrical sensitivity.” In order to read a book she must place it in a plastic bag which “blocks out the volatile organic compounds from the ink.” She also can feel the radio frequency emissions from a digital meter installed outside of her house by the electric company and “is convinced the emissions of countless objects are damaging her body...and her mind.” She is applying for disability and will likely succeed in obtaining it.

A paper published in the Journal of Virology by Korean researchers found that air contains between 1.6 million and 40 million viruses per cubic meter. If that’s not bad enough, a cubic meter of air also harbors between 860,000 and 11 million bacteria.

The good news is that a Florida man won a live roach-eating contest. The bad news is that he died at the scene. The prize for winning was to have been a python. The fate of the python is unknown.

According to a story, most joint US-Afghan operations have been suspended as NATO and US officers have just realized what the Soviets learned years ago. It seems the country of Afghanistan is not easy to manage. After yet another insider attack killed 4 of our soldiers last month, a senior military official said, “We’re to the point now where we can’t trust these people.” What took us so long to figure this out?

The head coach of a champion youth football team in California was suspended amid allegations that he offered his 11-year-old players bounties of up to $50 for the best hit of the game. The most money was to be paid for a hit that forced an opposing player to leave a game. He also is accused of altering uniforms to enable players to make weight limits. The bounties were established before news of a similar situation involving the New Orleans Saints of the NFL came to light.

A student at the University of Tennessee was hospitalized after allegedly getting drunk via an alcohol enema. The story states his blood alcohol level was 0.448 (6 times the legal limit) and he had rectal injuries. The student, who is planning to sue the school and the hospital for among other things, violating his HIPAA rights, denies that the enema occurred. In a press conference, he said that he and his fraternity brothers were only playing a game called “Tour de Franzia.” The game involves teams drinking bags of Franzia wine, vintage not stated, as fast as possible. The press conference, which features the student, his lawyer and to the lawyer’s right a lad who appears to be “Flounder” from the movie “Animal House,” can be seen here.

How to lower hospital readmission rates: Let 'em die

As new Medicare rules kick in, some 2200 hospitals nationwide are facing financial penalties for high 30-day readmission rates for myocardial infarction, congestive heart failure and pneumonia. Medicare payments will be lowered by as much as 1%.

Investigators at the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research (SSIEBOAR, catchy acronym, don’t you think?) have come up with a plan that is certain to lower readmission rates across the board. Some have said the idea should be patented but the institute is not-for-profit and thus is willing to share.

The solution is quite simple—let the patients die. Yes, death reduces readmission rates for all diseases, not just MI, CHF and pneumonia.

Oh, there may be some resistance and relatives of the patients may complain, but at least Medicare will be satisfied and after all, isn’t that why we became doctors?

Another outcome measure, hospital length of stay is also positively impacted by death. For example, if the average length of stay for a patient with a heart attack is 4 days, a patient who dies on hospital day #2 would lower the hospital’s average. Death also results in fewer resources being utilized, which saves the hospital money for those patients whose reimbursement is based on the DRG.

I confess. I’m not serious, and the idea is not original.

There are many issues. In most cases, as length of stay is ratcheted down, readmission rates will rise. One way to reduce readmissions is to keep patients in the hospital longer. And what about the things the hospitals and doctors can’t control? A recent study found that only 63% of Medicaid patients with diabetes, hypertension and hypercholesterolemia actually took their medications regularly.

So what is the solution?

Assessing quality of care in hospitals is a difficult task. People like me have complained about focusing on processes such as the Surgical Care Improvement Project because adherence to process measures does not always correlate with good outcomes. [See previous blog here.] However, processes are much easier to track than outcomes.

The problem with outcome measures is that experts can’t agree on which ones to measure. Even something as seemingly straightforward as death can actually be complex. A 2010 paper in the British Medical Journal on this subject was reviewed in a blog, which pointed out the difficulties with death as a benchmark. This holds true even when death is adjusted for risk.

Readmission rates are also controlled by physicians, not hospitals. Even concurrent review of readmissions by hospital utilization staffs has not been effective in reducing these numbers.

There is another factor. Here’s an anecdote that might help you understand the problem. An elderly woman was admitted for congestive heart failure. After a few days of intense medical care, she was discharged. She was readmitted for CHF three days later. When interviewed during her history and physical exam, she admitted that she 1) did not take any of her prescribed medications at home, 2) continued to smoke cigarettes and 3) did not follow her cardiac diet.

Is it really fair to penalize hospitals for readmissions, many of which cannot be prevented?

The effect of the robot on surgical education

Having taken an extended break from writing about the problems associated with robotic surgery, I think it’s time to explore an area not previously discussed.

What is the effect of the robot on surgical resident education?

The robot at the OR table (babe not included).

Let’s review a few points about robot-assisted surgery. The surgeon actually doing the case is not scrubbed. He sits at a console away from the patient and manipulates the instruments. Another doctor has to scrub and insert the instruments through small incisions and “dock” (connect the instruments) to the part of the robot that is next to the patient. 

The assistant at the patient’s side views the operation on a video screen. Sources tell me that residents get to do a lot of docking, observing, inserting and removing instruments and closing incisions but not much time, if any, at the console doing the operation.

There is a dual console capability but many hospitals do not invest in it because of the added cost of the fully equipped second console.

Two consoles. Resident (left) shown participating in the operation.

So how are the residents going to learn to perform surgery? There is already evidence that they lack confidence in their ability to operate independently. See my earlier blog on this subject.

The majority of graduating chief residents in surgery take at least one year of fellowship training. One can only hope that they train in a hospital that has at least one dual-console robot or they may end up practicing on you and me.

Cranberry juice may help lower BP but…

All you need to do is drink two 8 ounce glasses of cranberry juice per day for 8 weeks and your blood pressure will be statistically significantly lower. So states a randomized, blinded placebo-controlled trial presented at this year’s American Heart Association's High Blood Pressure Research.

According to the MedPage Today report, mean diastolic blood pressure fell by a whopping 3 mm Hg from baseline at the end of the study period. The difference was significant at the level of p = 0.049. Subjects given placebo showed no change in their average BP.

Unfortunately, as appealing as this may sound, it’s another situation where statistical significance and clinical significance part ways. I have blogged about this before.

What are the problems with cranberry juice study?

The subjects were people of normal body mass index (average BMI, 28) who did not have hypertension.

The mean fall in diastolic blood pressure was from 72 mm Hg to 69 mm Hg, both of which are in the normal range. A 3 mm Hg difference in diastolic blood pressure, even if it had occurred in a patient with hypertension, is not a clinically important difference.

Systolic BP also fell by 3 mm Hg but the difference was not statistically significant, p = 0.12. A quote from the article states, “The trend didn't meet traditional criteria for statistical significance, but the 89% odds of a systolic blood pressure reduction with the cranberry juice was still pretty good, [a study author] suggested.” Sorry, not only is that baloney, a 3 mm Hg difference in systolic BP is also not clinically important.

A study from the Mayo Clinic found that when blood pressure is measured every 10 minutes throughout the day in healthy adults, both systolic and diastolic BPs varied as much as 8 to 10 mm Hg whether the subject was active or not. This indicates that a 3 mm Hg difference is very likely to have occurred by chance.

Finally, the study was funded by Ocean Spray Cranberries and one of its employees was a co-author.

You can drink cranberry juice if you like its taste, but don't throw away the BP pills.